STEPHEN LEEDER. Employing less qualified people in aged care

Sep 19, 2018

The Royal Commission announced this week will have a full agenda. If it can help us get aged care back on track we will all be the richer.

One Saturday morning ten years ago, I took a phone call from the nursing home where an elderly, moderately demented relative resided. The facility was humane, professional, warm and near our home. “We’re calling to let you know that we are about to send her to hospital.” This was unexpected.  What was the problem? “She keeps holding her head to one side.” Had they considered calling her GP? “He’s not available on the weekend.” So I visited.

She was, indeed, holding her head at a strange angle, but happily wolfing down her lunch. “Can you straighten your neck?” I asked, demonstrating. She smiled and complied.

What it was all about I have no idea. But I felt pleased to have avoided her admission – ambulance, ED, unfamiliar ward, disorientation, perhaps a fall (with or without fracture), a week or ten days in an alien place, perhaps an infection?  

(Lest you imagine that I am dissing the GP, I’m not. He and his partner provided exemplary palliative care in her final days eight years later and high-quality service for the years in between. It’s the system that sucks.)

Earlier this year, the AMA has made an extensive submission to the Aged Care Taskforce concerning residential aged care facilities.

This document derives largely from the practical experience of doctors doing their best – within the logistic constraints of workload and organisation – to provide care for older people. The AMA’s executive summary states:

An Aged Care Commission should be introduced to streamline the aged care system, and should include a role that ensures there is an adequate supply of appropriate, well-trained staff to meet the demand of holistic care to a multicultural, ageing population, and also to ensure the aged care workforce has clear roles and responsibilities.

A permanent commission is an aspiration that the Royal Commission may wish to consider.  Right now, staffing of residential aged care facilities is a disgrace. “Our members have reported cases where nurses are being replaced by junior personal care attendants, and some residential aged care facilities do not have any nurses staffed after hours.”

The AMA illustrates the worsening problem.

The proportion of Full Time Equivalent employee types in the residential aged care workforce. Data source: Mavromaras et al (2016) The aged care workforce, 2016. Department of Health

Between 2003 and 2016, personal care attendants rose from 55% to 72% of this full-time workforce. Registered nurses decreased from 22% to 15%.  Other skilled workers have declined proportionately. Nurse practitioners, a great asset in this context (based on overseas experience in systems such as Geisinger Health make up a tiny fraction of the workforce, as do allied heath professionals.  

We are progressively accepting the need for integrated care between hospitals and the community for multi-morbid, frail patients. The crucial role, in this effort, of GPs and nurse coordinators is coming to be understood, and to some extent, resourced. This redeployment of staff and effort is no small deal – much change remains to be managed. In the light of this move, now is the time to take account afresh of what is needed to re-fit aged care facilities to participate more fully in providing integrated care.

The AMA document also explores the context within which residential aged care is provided. It points out that, in 2013, 32% of the Australian population (5.8 million people) were born overseas. “This presents a major challenge in the form of incorporating different cultures into aged care, and communication with individuals [including families] who may have low levels of English literacy.” But this observation weakens somewhat when you consider the 2016 census figures that show that the percentage of the population not speaking English at home is only around 21%.

Care for older Aboriginal and Torres Strait Islander people is another cultural challenge we have done little to accept.

The submission concludes by re-stating the centrality of workforce – adequate education, adequate funding, and adequate numbers.  This is the problem demanding immediate attention.

Stephen Leeder is an emeritus professor at the University of Sydney.  This article is an edited version of an article published in Australian Medicine in May this year.

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